treating women for opioid use disorder in the era of covid-19

Treating Women for Opioid Use Disorder in The Era of COVID-19

Hendrée E Jones, PhDExecutive Director, UNC HorizonsProfessor, Department of Obstetrics and GynecologyUniversity of North Carolina

10/8/2020

Virtual

No conflicts of interests to declare related to the content of this presentation

IntroductionOutline

• An Epidemic in a Pandemic

• Considerations/concerns related to COVID-19

• How substance use disorder treatment services have changed

• Challenges regardless of COVID-19

• Clinical pearls https://pixabay.com/photos/coronavirus-virus-mask-corona-4914026/

Rising Substance Use Epidemic in a Pandemic

Drug Use Increase During COVID-19Epidemic in a Pandemic

Epidemic in a Pandemic

Overlapping Risks: Substance Use Disorders and COVID-19- Social and Psychological Issues

The social and psychological risks of the pandemic can favor and intensify drug use, in a potentially catastrophic cycle


• Negative emotionsSocial Distance

• Anger, fear, irritability• AnxietyIsolation

• Sadness• BoredomQuarantine

COVI

D-Sa

fety

Ornell F et al., Psychiatry Res. 2020 Jul; 289: 113096.

Triggers for Return to use or escalation of use

COVID-19- The Perfect Storm

Health anxiety and fears

People with SUD have even higher level of distressFragility of traditional support systems/ access to medical care, and community support agencies

Financial loss/ stressLoss of daily routine

Loss of pleasurable activitiesLoss of social interaction

Psychiatric symptoms and psychological distress


COVID-19 and PregnancyConsiderations/concerns

related to COVID-19• How does coronavirus affect pregnant people?

• How will COVID-19 affect prenatal and postpartum care visits?

• Providers need to • Help with stress/anxiety/depression• Look for abusive relationships

• Have a birth plan• Can you breastfeed if you have COVID-19?

https://pixabay.com/photos/consultation-assessment-medicine-3486590/

https://www.acog.org/en/Patient%20Resources/FAQs/Pregnancy/Coronavirus%20Pregnancy%20and%20Breastfeeding

SUD Treatment Slowed during COVID-19

WHO declared a pandemic on March 11, 2020SUD treatment programs were stopped due to recommendations for physical distancing.

Those that remained open, substantially reduced their number of admissions or started providing care remotely.Many peer-support agencies shut downPhone interventions for alcohol use disorders are both feasible and acceptable

14 digital applications for the delivery of treatment for alcohol use disorders.Growing demand is propelling many organizations and providers to leap toward remote delivery of care, equity consideration such as the socioeconomic vulnerabilities of persons with SUD need mitigation strategies. Mutual-aid support groups such as Alcoholics Anonymous, Narcotics Anonymous, and SMART recovery are traditionally delivered in-person. However, in the context of COVID-19, mutual support programs via online platforms are rapidly burgeoning.

How substance use disorder treatment services have changed

SAMHSA Allows More Flexibility for Opioid Treatment Programs (OTP)


3/16/2020 (Updated 3/19/2020) Opioid Treatment Program (OTP) Guidance SAMHSA recognizes the evolving issues surrounding COVID-19 and the emerging needs OTPs continue to face. SAMHSA affirms its commitment to supporting OTPs in any way possible during this time. As such, we are expanding our previous guidance to provide increased flexibility.

FOR ALL STATES The state may request blanket exceptions for all stable patients in an OTP to receive 28 days of Take-Home doses of the patient’s medication for opioid use disorder.

The state may request up to 14 days of Take-Home medication for those patients who are less stable but who the OTP believes can safely handle this level of Take-Home medication

Innovation During COVID-19: Improving Addiction Treatment Access- Medications to Treat OUD

Federal guidance allows for use of audio-only telehealth for buprenorphine induction without requiring an in-person evaluation or video interface

Rhode Island Buprenorphine Hotline- 24 hour "tele-bridge" clinic where people with OUD can be linked with a DATA 2000 waivered provider who can provide an initial assessment and, if appropriate, prescribe buprenorphine for unobserved induction and linkage to maintenance

Physical "bridge clinics" have been established in many health systems to fill gaps in care for people with opioid use disorder and have shown high rates of retention and linkage to treatment.


Samuels EA. Et al., Journal of Addiction Medicine 2020:14(4): p e8-e9

Innovation During COVID-19: Improving Addiction Treatment Access- Medications to Treat OUD

The sustainability of using telehealth for buprenorphine initiation relies heavily on legislative and regulatory changes. The Ryan Haight Online Pharmacy Consumer Protection Act prohibits the prescription of controlled substances without an initial in-person visit with a provider.

Enacted to prevent the trafficking of opioid medications by online pharmaceutical companies, this federal law has limited the use of telehealth for buprenorphine initiation with very narrow exceptions including a declared state of emergency, as we have seen with the COVID19 pandemic.

Opioid Epidemic has felt like a state of emergency to many of us for some time. If the current federal guidelines instituted during the COVID-19 pandemic are to be adopted permanently, not only could we expand medication access for patients with opioid use disorder, we would also be able to study the efficacy of this low-threshold care model over time.


Samuels EA. Et al., Journal of Addiction Medicine 2020:14(4): p e8-e9


COVID-19 –An Opportunity for Change

• No evidence that forcing methadone clinic morning visits improves outcomes- evidence that it reduces access

• The FDA should make naloxone available over the counter

• States should remove paraphernalia laws which criminalize possession of equipment for drug consumption, including sterile syringes

• Crimes of poverty should be addressed with evidence-based services, not jail time


Issues Women in SUD Treatment Face Regardless of COVID-19

How to Address Tobacco Use/Smoking

There were two themes related to the role of smoking in the women's lives:

(1) smoking facilitates socialization

(2) smoking as a coping mechanism

There were three themes related to the benefits of tobacco-free policy:

(1) improved health

(2) support for continued abstinence from a previous tobacco-free placement (eg, prison)

(3) less grounds up-keep

Barriers to tobacco-free policy included

(1) lack of an alternative coping mechanism to smoking

(2) fear that a tobacco-free policy would drive women away

(3) anticipation of implementation challenges

Challenges regardless of COVID-19

Fallin-Bennett A et al., Nicotine Tob Res. 2018 Sep 25;20(11):1386-1392.

“The year after delivery is a vulnerable period for women with OUD.

Additional longitudinal supports and interventions tailored to women in the first year postpartum are needed to prevent and reduce overdose events.” Schiff DM et al., Obstet Gynecol. 2018

� Challenges the dyad faces�Newborn care, breastfeeding, maternal/infant bonding�Mood changes, sleep disturbances, physiologic changes� Cultural norms, “the ideal mother”

� System issues�Medical care contact shifts from mother focus to pediatric focus�Maternal contact often is with social services� Insurance changes� Treatment for substance use disorders may change

The Overlooked 4th Trimester Challenges regardless of COVID-19

Rising Maternal Mortality: Harmful Policies in the Postpartum Time

18.8 19.2 19.5 19.9 20.3 20.6 21 21.3 21.7 22 22.4 22.8 23.1 23.5 23.8

0

5

10

15

20

25

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

per 100,000 live births

Likely Drivers

MacDorman MF et al Ob/Gyn 2016

“Detox” during pregnancy to prevent NAS

Medicaid coverage loss at 6 weeks postpartum

Inadequate Access to substance use disorder treatment/Medication

Substance use with homicide/suicide

Overdose

Source: Whiteman VE et al., J Pregnancy. 2014;2014:906723

Both informal and official custody loss predicted increased drug use, and informal loss predicted increased criminal involvement. Child custody loss has negative health implications for African American mothers, potentially reducing their likelihood of regaining or retaining custody of their children. Harp KLH, Oser CB. Child Abuse Negl. 2018 Mar;77:1-12.

Incarceration “detox”


Facilities Providing Some Medication Treatment for Opioid Use Disorders (2020)

National: 6,610

Key:

1

2

3 Number of substance abuse treatment facilities offering any medication to treat

opioid use disordersData Source: Substance Abuse and Mental

Health Services Administration.

opioid.amfar.org

Medication Treatment for Opioid Use Disorders Remains Scarce Challenges

regardless of COVID-19

http://opioid.amfar.org/

Patrick SW et al., JAMA Network Open. 2020;3(8):e2013456


Medication Treatment for Opioid Use Disorders Remains Scarce for Pregnant Women

Thomas S et al., Contemporary Drug Problems Copyright © 2018 SAGE Publications

Arc of Polices Bends Towards Punitive Actions for Pregnant People Using Substances Challenges

regardless of COVID-19

UNC Horizons: Residential and Outpatient Family-Centered Care

Unified Philosophy Informed by Social Learning, Relationship and Empowerment Theories

Trauma andSUD

TreatmentChildcare and

Transportation

VocationalRehabilitation

Housing Legal aidParenting

Education andEarly

Intervention

Medical CareIntegrated OB/GYN clinic

Psychiatry

2 Residential sites*(40 beds)

and/or OutpatientCare

(Raleigh and Carrboro)

Med

icat

ion

Assis

ted

Trea

tmen

t

Mother & Child

Trauma-Inform

ed and Responsive Culture

Clinical pearls

Who We Serve 2018-2019 Served 235 women

• 70% Primary OUD; 13% alcohol

• Mean age first substance use 15 years old (as early as 5 yrs)

• 25% reported prior Traumatic Brain Injury

• 50% pregnant at intake

• Outcomes• Babies born at term and normal birth weight

• 73% employed at completion

• 95% CPS outcomes were positive at completion

Clinical pearls

Clinical pearlsUseful Tips: What Works

• Educate and repeat!

• Develop a list of emergency contacts and policies/procedures for how staff will respond to outpatient patient crises

• Sat down with each patient to assess their ability to use tele-treatment platforms and continue to troubleshoot

• Explicit conversations with patients around confidentiality and guidelines for engagement

• One designated medical authority (Elisabeth) to disseminate information to staff on the latest safety and PPE guidelines related to COVID-19.

• Help women develop a birth plan, share with providers and talk about support due to no visitors

• For residential settings - set aside units so newly arriving women can isolate for two weeks in their apartments with staff bringing them medication, groceries, group handouts, etc.

Useful Tips: What to Avoid/Challenges• COVID-19 media overload- limit consumption

• Movies and other multimedia tools are less effective

• Avoid relying on written memos with patients for communication

• NA/AA network hard to grow. Women report fatigue with the online platform

• Women preparing to leave the program are understandably concerned about their ability to find employment, housing, recovery networks, etc.

• Sometimes have to ask women to step away or put on headphones if we see or know that a child is in the same room listening to the discussion

• This also means being flexible and re-scheduling sessions if the patient’s children are having a rough day

• Heightened concerns around abuse and neglect of children and risk for interpersonal violence exposure for patients -providing more clinical contact than pre-COVID-19 days

• Attention is needed to eliminate the disparities that COVID-19 further highlights

Clinical pearls

https://pixabay.com/photos/caution-hazard-stop-grass-outdoor-3402597/

What The Women Shared

• COVID-19 and the sheltering in place is triggering- ways I used to act in addiction I see coming back- but I have coping skills now to deal with the feelings

• Isolation is a huge trigger

• Helps to be able to go out and walk, to have a routine

• Having tools to work on education from home helps

• Having tools to find employment helps

• Want providers to know how hard it is to have the same day every day

• Be patient with us and have empathy for us because sometimes we need a break from our kids

• Glad to have PPE for self and kids

• Stop the discrimination against us- last week a non-UNC nurse taking a drug test from me said “if an addict’s lips are moving, then she is lying.” “My test was negative but I felt judged and like I was less than dirt.”

Clinical pearls

https://pixabay.com/photos/window-view-sitting-indoors-girl-1081788/

An Attitude of Gratitude Clinical Pearls

• Meetings start with gratitude

• Email and handwritten notes of thanks

• Calling to check on all team members

• Finding joy in your day

• Sending a though for the day every day as well

• As fun tips for the team and fun tips for patients to do with their children

• Tokens of thanks given

• Modeling patience, empathy, self-compassion and self-care

Dealing With ZOOM Fatigue Clinical Pearls

• Why do we get so fatigued after video-conferencing all day?• Cognitive overload • Looking at your own face as you communicate • No space between one encounter and another. • Primary source of social connection right now

• What can you do to mitigate fatigue?• Digitally detox• Don’t show your face on your view of Zoom platforms• Switch it up• Be thoughtful about how you use video calls• Choose who you invite• Avoid scheduling back-to-back meetings• Take care of yourself! MOVE AROUND!!!!!

Final SlideSummary

• An Epidemic in a Pandemic

• Considerations/concerns related to COVID-19

• How substance use disorder treatment services have changed

• Challenges regardless of COVID-19

• Clinical pearls https://pixabay.com/photos/coronavirus-virus-mask-corona-4914026/

Thank you

Thank you for your attention!

Questions?

Contact: [email protected]

treating women for opioid use disorder in the era of covid-19

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